Risultati per: Follow-up ottimale dopo embolia polmonare acuta

Svolta per i casi più difficili, studio italiano

Svolta per i casi più difficili, studio italiano

Stroke, Volume 54, Issue Suppl_1, Page AWMP55-AWMP55, February 1, 2023. Background:Current guidelines encourage early vascular imaging to assess for large vessel occlusions (LVO) in patients presenting with NIHSS ≥ 6 to establish candidacy for mechanical thrombectomy (MT). In patients with low NIHSS, the benefit of early vascular imaging is uncertain. Cortical signs such as aphasia, neglect or visual field deficits on the exam have been used to identify patients with LVO. Still, the utility of these clinical signs in low NIHSS is unknown.Methods:This is a retrospective analysis of all acute ischemic stroke patients who presented directly to our comprehensive stroke center (CSC) from December 1, 2020-May 31, 2021. All patients had CT angiography (CTA) or MR angiography (MRA) of the head and neck with timing at the discretion of the treating neurologist.Results:Of the 167 patients [median age 70 IQR (58-78), 50% female, 64% African-American], 85 (51%) presented with NIHSS of 0-5. Compared to patients with NIHSS ≥ 6, patients with NIHSS of 0-5 were younger (median age 66 vs. 70, p= 0.039) and had less congestive heart failure (0.6% vs. 4.8%, p=.014). Upfront CTA with initial non-contrast CT head was done less in patients with NIHSS 0-5 (65% vs. 85%, p=.002). Patients with NIHSS 0-5 had fewer LVO (13% vs. 44%, p

Stroke, Volume 54, Issue Suppl_1, Page ATP76-ATP76, February 1, 2023. Introduction:Improving rates of in-hospital survival in intracerebral hemorrhage (ICH) have led to opportunities to implement secondary prevention and recovery measures. Lost to follow up is not well characterized in this disabled population. The objective of this analysis was to describe the frequency of lost to follow up for ICH survivors from an urban comprehensive stroke center and thrombectomy capable center.Methods:We included n=409 ICH patients from December 2016 to February 2022. With chart review, we collected data regarding the admission, discharge and follow-up. Our primary outcome measure was a modified Rankin scale (mRS) score of 0 – 3 during their last recorded follow-up. Pearson correlation analyses were performed using R statistical software to determine if there was a significant correlation between the number of follow-ups a patient received and their final recorded mRS score.Results:Of 409 ICH patients, 80 died within the first month of their index hospitalization or had incomplete records that prevented further analysis. Of the 329 patients, 181 were minorities (83 blacks, 49 asian and 49 hispanics) and 90 were white. About 85% (279/329) had insurance. Only 162 received 3 or more follow-ups post-index hospitalization, with 47 patients never receiving any follow-ups after their initial discharge. Of those that received follow up, the average number of follow ups was 2.57, with an average time of 366.17 days between discharge and the last recorded follow-up. Among the 282 patients that received at least one follow-up, there was a significant negative correlation between the number of follow-ups a patient received and their final recorded mRS score (p = 0.0000339, r = -0.246). There was no significant differences related to age, race or insurance status for those who followed up versus those who were lost to follow up.Conclusions:In a large urban health system, 14% ICH survivors were lost to follow-up. ICH survivors with good functional outcomes received more follow-up. There is a need to improve systems of care to prevent ICH patients from getting lost to follow-up and improving long term outcomes.

Stroke, Volume 54, Issue Suppl_1, Page AWP78-AWP78, February 1, 2023. Introduction:Stroke is a leading cause of economic burden in the Low Middle Income countries (LMIC’s). We want to study the outcome of acute strokes treated under Government scheme with minimal package (For Ischemic Stroke – 257 USD & For hemorrhagic stroke – 399 USD), but offered evidence-based stroke care other than thrombolysis.Methods:From January 2021 to March 2021, a total of 350 cases were treated in our Ankineedu stroke center. Out of these 125 (36%) acute stroke patients are treated under subsidized economical stroke care from admission to discharge. In-patient mortality, 3 months follow up and 1 year follow up recorded. All patients received standard medical treatment in Stroke unit with Antiplatelets, statins, DVT prophylaxis, Antihypertensives, dysphagia assessment, physiotherapy and Neurosurgery when required. All basic stroke investigations done – CT scan, MRI scan, MR Angio, Neck vessel doppler, Lipids, Renal Function test, RBS, ECG and ECHO. All patients discharged on secondary prevention. Average length of stay is 10 days.Results:There were 94 men and 31 women, age ranged from 18 years to 85 years (median 55 yrs). Type of stroke: Ischemic Stroke -74% and Haemorrhagic stroke – 26%, 4 patients (3.2%) underwent Neurosurgery. Risk factors: Hypertension – 82 (66%), Diabetes – 45 (36%), Cardiac problems – 17 (13.6%), Smoking – 20 (16%), Alcohol – 15 (12%). Total In-house mortality 5 (4%) and the remaining patients outcome at 3 months – Good outcome with modified rankin scale (mRS) 0-2 in 83 patients (66%), Fair Outcome with mRS (3-4) – 35 (28%), 1 patient (0.8%) bedridden and 1 patient (0.8%) died at home. Out of 125 patients, 60 patients (48%) came for 1 year follow up, of these 88% had mRS (0-2), 12% had mRS (3-5).Conclusion:In resource poor countries we can offer basic stroke care model to all needy patients with reasonable outcome. However, the follow up needs to be strengthened.

Stroke, Volume 54, Issue Suppl_1, Page ATMP2-ATMP2, February 1, 2023. Background:The unknown onset stroke can be categorized into two groups; wake-up stroke (WUS) and non-wake-up unwitnessed stroke with a time of onset unavailable due to aphasia, impaired consciousness, or cognitive impairment (non-wake-up unknown onset stroke, non-WUS). We aimed to assess the differences in efficacy and safety of intravenous thrombolysis (IVT) for these subgroups.Methods:Patients with an unknown onset stroke from the Evaluation of unknown Onset Stroke thrombolysis trials (EOS) collaboration were evaluated using an individual patient-level database of randomized controlled trials comparing IVT with placebo/standard treatment. A favorable outcome was defined as a modified Rankin Scale score 0-1 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) at 22-36 hours and 90-day mortality. The effect of IVT was compared between the treatment groups in the WUS and non-WUS with mixed-effect logistic-regression analysis.Results:A total of 634 patients (233 women [36.8%], median age 70 years [IQR 61-76]) were analyzed. In patients with non-WUS (n=92 [14%]), advanced age, atrial fibrillation, vessel occlusion on MRA and high NIHSS score were more prevalent (P

Stroke, Volume 54, Issue Suppl_1, Page A114-A114, February 1, 2023. Background:Quantitative susceptibility mapping (QSM) is a measure of iron content, and ≥6% increase in QSM has been correlated with new hemorrhage in previously stable cavernous angiomas. Longitudinal changes in QSM are not known in cavernous angiomas with symptomatic hemorrhage (CASH) with high rates of rebleeding and are the targets of novel pharmacotherapies. In a prospective multisite Trial Readiness project (clinicaltrials.gov NCT03652181), QSM is longitudinally assessed.Methods:Trial eligible subjects with CASH in the prior year and not undergoing lesion resection or radiation, were enrolled. Mean QSM of CASH lesion was acquired at baseline and at 1 and 2 year planned follow-ups. Relative change in mean lesional QSM during each follow-up year was assessed, and any symptomatic hemorrhage (SH), asymptomatic changes (AC; defined as subclinical bleed or growth) in the lesion during the same epoch.Results:Paired QSM assessments were completed to date in 99 CASH lesions (67 year 1, and 32 year 2) and are reported herein. Four SH and 6 ACs occurred during 1stfollow-up year, and 3 SH during 2ndyear. QSM increased in 54 lesion-years, decreased in 44, and remained stable in 1. The % lesional QSM change in year 1 was significantly higher than that observed in year 2 (mean +9.33, SD 37.52 vs. +5.20; SD= 24.86; p=0.05; Spearman correlation ρ -0.36). CAs with clinical SH or AC had a significantly higher % QSM change than lesions without (mean +28.03, SD 17.77 vs. +4.97, SD= 34.75; p=0.0014). All 13 lesions with SH/AC demonstrated a QSM increase ≥6% while 31 of 86 (36%) lesions with no clinical events had a ≥6% QSM increase.Conclusion:QSM change of ≥6% is present in every CASH lesion manifesting a new SH or AC (100% specificity), and is more common than clinical events (3.4X higher sensitivity). The biomarker can hence be used as a more sensitive categorical outcome than SH or AC in clinical trials of novel therapies aimed at bleeding in CASH lesions. Effect of an intervention on % QSM change may also be proposed as a time-averaged difference between 2 arms using a repeated measures analysis implemented as an unadjusted linear mixed model. These results are the basis of application for certification by the U.S F.D.A. of QSM as a monitoring biomarker of drug effect in CASH.

Stroke, Volume 54, Issue Suppl_1, Page ATP75-ATP75, February 1, 2023. Introduction:Up to 25% of strokes are recognized upon awakening. Recent studies have demonstrated that a “tissue clock” rather than a time clock can be used to identify patients who may benefit from intravenous thrombolytics (IVT) beyond 4.5 hours from last known well (LKW). Consistent access to hyperacute MRI limits many centers from treating wake-up stroke patients. We created a formal protocol of clinical and imaging criteria to standardize evaluation and management of wake-up strokes.Methods:This retrospective, observational study reviewed consecutive patients admitted to our Comprehensive Stroke Center who qualified for the wake-up protocol between February 2022 and June 2022. The implemented protocol, based on clinical trials’ inclusion criteria, is comprised of the following: 1) arrival within 12 hours from LKW and within 4.5 hours from symptom discovery; 2) high suspicion for acute ischemic stroke; 3) no contraindication to MRI; 4) NIHSS of at least 4; 5) baseline mRS 0-3; 6) no absolute contraindications to IVT. For patients meeting above inclusion criteria, emergent MRI with perfusion was performed. Diffusion-FLAIR mismatch (signal intensity ratio) and diffusion-perfusion mismatch were reviewed to determine thrombolysis eligibility by a trained neuroradiologist or vascular neurologist.Results:Ten patients qualified for the wake-up protocol in the first five months of protocol implementation. Median NIHSS was 7, median LKW to arrival time was 8 hours, and median door to MRI time was 72.5 minutes. A final diagnosis of ischemic stroke was made in 80% of these cases. Overall, 50% were eligible for IVT based on our criteria, and 30% received thrombolysis. Median door to needle time was 92 minutes (range 75-117). There were no symptomatic intracranial hemorrhages. All patients treated with IVT were discharged home with no to minimal residual deficits with mRS 0-1 and median NIHSS at discharge of 2 (range 0-4).Conclusion:A formal protocol for wake-up stroke management allowed a streamlined approach to expand the number of IVT-eligible cases. Continued efforts are needed to improve door to needle times in such cases and to follow clinical courses of treated patients.

Stroke, Volume 54, Issue Suppl_1, Page AWP84-AWP84, February 1, 2023. Intro:To address gaps in intracerebral hemorrhage (ICH) outcomes, acquisition of long-term data is necessary and resource intensive. We present our experience from follow-up of ICH patients across a 7-hospital certified stroke healthcare system.Methods:From 01/21 to 07/22, follow-up calls were made to adult non-traumatic ICH patients at 30, 90, 180, and 365-day timepoints (TP) post discharge. Consent was obtained at first successful contact, followed by collection of functional, cognitive, and quality of life outcomes. Trained research staff made multiple attempts (calls per patient) to complete assessment at each TP. An attempt was deemed successful if contact was made with a patient/proxy. We report overall and TP-specific rates of successful contact, consent, and completion using logistic regression. We also report the association of individual call success with attempt number and day of week.Results:Overall, 2,214 call attempts were made for 375 patients, of whom 246 (70.7%) were successfully contacted at least once. Of contacted, 173 (70.3%) consented, and 147 consented patients (85.0%) completed all assessments at one or more TPs (Fig A). Proportion of successful contact at 365-day (60.7%) was significantly higher compared to other TPs (Fig B). Consent rate was non-significantly higher for 30 and 90-day TPs (74.4%) compared to 180 and 365-day (68.1%). Conversely, patients were significantly less likely to complete assessments at the first three TPs compared to 365-day. For individual call attempts, first attempts were 1.5-2.4 times more likely to be successful than subsequent attempts, and calls made on Thursdays were 42-52% more likely to be successful.Conclusion:We demonstrate the need to consent patients early in their recovery when they are likely most motivated. As completion rates were lower at early vs. late TPs, we recommend curtailing laborious assessments at early TPs to decrease patient burden and continuing longitudinal follow-up.

Stroke, Volume 54, Issue Suppl_1, Page AWMP81-AWMP81, February 1, 2023. Background:Pathophysiology of intracranial atherosclerotic stenosis (ICAS) development and subsequent stroke occurrence is diverse, including cholesterol deposition, arterial dissection, and intrinsic vasculopathies. To differentiate these specific etiologies, performing high-resolution MRI (HR-MRI) has increased. However, the information on serial change of ICAS on HR-MRI was limited.Methods:Patients hospitalized at a tertiary university hospital for AIS and who took HR-MRI more than twice between 2015 and 2019 were collected. Two specialists manually segmented the contour of the culprit and reference vessel’s inner lumen, outer wall, and plaque. The stenotic degree, remodeling index, and enhancement signal were measured for the culprit lesion at each examination.Results:A total of 202 HR-MRI examinations from 93 patients were analyzed. The Median follow-up was 270 days (118-390). The ranges of the serial change in stenotic degree (-86% to 41%), remodeling index (-83% to 266%), and enhancement signal (-85% to 71%) were very diverse. Changes in stenotic degree and enhancement according to the initial stenotic degree were insignificant. On the other hand, the change in enhancement signal was greater in the initially more enhanced lesions (0.1±23.0; mild vs. -23.1±22.6; moderate vs. -35.5±28; severe, pdifference

Stroke, Volume 54, Issue Suppl_1, Page ATP107-ATP107, February 1, 2023. Background:24h CT is routinely acquired post-thrombolysis. Parenchymal hematoma and brain edema are feared complications. Predicting complications that change management would help reduce unnecessary imaging.Objective:To evaluate the utility of 24h per-protocol CT scan for stroke patients after thrombolysis.Methods:A prospectively collected cohort of consecutive patients presenting with acute ischemic stroke to our hospital from 2013- 2021 who were treated with IV tPA without undergoing endovascular therapy was entered into our IRB-approved stroke registry. Neuroimaging performed within 48h after admission was reviewed. Patients’ demographics, past medical history, admission National Institute of Health Stroke Scale (NIHSS) score, and medical variables were obtained. The primary outcome was significant radiologically findings (parenchymal hematoma or midline shift/herniation) leading to change in management (additional monitoring, emergent procedure, administration of mannitol or alteration in blood pressure goal).Results:From 2013 to 2021, 875 patients (mean age 69) who had IV tPA without undergoing endovascular therapy were identified, of which 472 (47.1%) were female. Median (IQR) NIHSS score was 9 (4-16) on admission. Imaging findings: 339 (38.7%) had expected evolving infarctions; 106(13.3%) developed any type of hemorrhagic transformation, including 66 (7.5%) who had hemorrhagic infarction and 50 (5.7%) parenchymal hematomas; 142(16.2%) developed any kind of mass effect, including 63 (7.2%) who had mild mass effect and 79 (9.0%) midline shift/herniation. There were 124 patients (12.1%) had significant findings (including parenchymal hematoma and midline shift/brain herniation) leading to change in the management. Patients who had significant findings had higher NIHSS score 16 (8-21) than those without 8 (4-15) (p

Stroke, Volume 54, Issue Suppl_1, Page A58-A58, February 1, 2023. Background:An individual’s atherosclerotic burden is associated with the cumulative exposure to vascular risk factors across the lifespan. We used the ARIC study to identify trajectories of atherosclerotic cardiovascular disease (ASCVD) risk over time and to evaluate their association with risk of stroke and cognitive impairment.Methods:We included cardiovascular disease-free ARIC participants with low or borderline ASCVD risk at the baseline study visit (10-year ASCVD Risk Score

Stroke, Volume 54, Issue Suppl_1, Page A86-A86, February 1, 2023. Background:Understanding the magnitude and causes of missing data is crucial to ensuring scientific integrity of clinical trials. Missing data threaten statistical and ecological validity, as results will only generalize to those who remain represented in the sample.Goal:Identify factors associated with loss at follow-up in acute ischemic stroke trials.Methods:We harmonized patient-level data from multiple NIH-funded acute ischemic stroke trials including NINDS IV-tPA, ALIAS part 2, SHINE, FAST-MAG, IMS-III, POINT, and DEFUSE 3, all of which had a 90-day study outcome. The primary outcome was the proportion of missing modified Rankin Scale (mRS) scores at 90 days. We compared patients with and without a 90-day mRS score among a variety of baseline patient characteristics.Results:Among 9580 subjects, 459 (4.8%) were missing their 90-day mRS. Age and race were associated with missingness. Compared to those with complete data, participants with missing data were younger (62 vs 66 years, p

Stroke, Volume 54, Issue Suppl_1, Page AWMP49-AWMP49, February 1, 2023. Introduction:CT performed 24h post-treatment is widely used to assess radiological outcomes in stroke studies. Even without visible hyperattenuation, occult angiographic contrast may persist in the brain and confound Hounsfield Unit-based imaging metrics such as Net Water Uptake (NWU), a measure of cerebral edema based on tissue hypoattenuation. We aimed to assess (1) the presence of retained contrast post-thrombectomy on 24h CT by comparing NWU measurements with and without adjustment for iodine using dual energy CT (DECT), (2) factors associated with amount of retention, and (3) its impact on the accuracy of NWU.Methods:In a prospective study of patients with anterior circulation large vessel occlusion who had post-thrombectomy follow-up DECT performed 24h post-treatment from two Comprehensive Stroke Centres (November 2021 to May 2022), NWU was calculated by interside comparison of Hounsfield Units of the infarct lesion and its mirror homolog. Retained contrast was quantified by the difference in NWU values with and without adjustment for iodine. We tested correlation between NWU and tissue swelling using relative hemispheric volume (rHV) and midline shift (MLS). Patients with visible hyperdensities from hemorrhagic transformation or visible contrast retention, and bilateral infarcts were excluded.Results:Of 125 patients analysed (median age 71 [IQR 61-80], baseline NIHSS 16 [IQR 9.75-21]), reperfusion (eTICI 2b-3) was achieved in 120 patients (96.8%). NWU measured with iodine adjustment was significantly higher than NWU measured without adjustment (17.1% vs 10.8%, p